Mnemonic for Assessing DEMENTIA

How do you know your patient is suffering from dementia? The word itself, DEMENTIA, can serve as useful memory aid to make sure you consider important reversible causes. The article also adds a couple of key concepts to help you make sure your assessment and diagnosis of dementia is accurate, thorough, and complete.

When I am assessing a patient and dementia is suspected, there are two key concepts I like to keep in mind: There is a difference between dementia and delirium, and dementia has both irreversible and reversible causes.

First, dementia is not the same as delirium. To keep it simple, I like to think of it this way: dementia is chronic/progressive and delirium is acute. I know that’s a bit of an over-simplification because new-onset dementia or worsening dementia can be confused with delirium. But if you are trying to get to the bottom of an acute situation vs a chronic situation, you will ask better questions during history-taking if you can keep it simple.

Second, dementia has both irreversible and reversible causes. Irreversible causes include multi-infarct or arterio-vascular causes (aka stroke/TIAs causing brain damage over time), Alzheimer’s disease, Lewy body dementia, Pick’s disease and other rare causes. The reversible causes overlap with delirium and this is where the rubber meets the road – this is where the mnemonic DEMENTIA can help you parse through the reversible causes of dementia and ensure the patient receives the proper care.

Reversible causes of dementia are ones we want to rule out first, and there are many. Remembering the word DEMENTIA is one way to recall most of the causes that are “reversible.” The following list contains some important things to consider and some key questions to ask when evaluating your patient for dementia. The list is not exhaustive, by any means, but it will point you in the right direction toward providing a thorough assessment of a patient with apparent dementia.

D= Drugs

Many common prescription drugs that are known to affect cognitive function: diuretics, anticholinergics, antihistamines, antispasmodics, benzodiazepines, bronchodilators, and more. Is your patient taking any of these drugs or others that may affect cognitive function? Remember the BEERs list! Are there any medications that are new to the patient’s regimen? Is the patient taking all prescribed medication as directed? When was the last dose? And, don’t forget to inquire about illicit drugs, including self-medication with cannabis.

E= Eyes and Ears

Both vision loss and hearing loss correlate with dementia. While the body of evidence around this correlative relationship is growing, it is important to consider vision changes and hearing changes in your assessment.

Significant visual changes beyond declining acuity can signal changes in brain function. For example, if you notice your patient is unable to perceive depth and dimension, has trouble with glare and shadows, is unable to discern individual objects of similar color, or experiences an increasing need for brighter light and simpler surroundings, further evaluation is needed.

While hearing loss is a widespread phenomenon, and is largely ignored as an expected consequence of aging, research shows that hearing loss and dementia go hand in hand. Whether hearing loss is a marker for early-stage dementia or a modifiable risk factor for dementia are hot topics for further research. Meanwhile, if your patient complains of hearing loss, the complaint deserves further evaluation.

M= Metabolic and Endocrine Disorders

Disorders of metabolism and the endocrine system such as thyroid dysfunction, diabetes, prolonged or excessive diarrhea and vomiting, decreased appetite and inadequate nutrition, can create symptoms that include delirium/dementia. Find out more with appropriate lab tests and questions about diet and stool habits.

E= Emotional Disorders

Depression and anxiety symptoms often accompany dementia. It’s important to remember that inappropriate behavior, repeated falls, incontinence, and inability to perform ADLs and self-care can sometimes have emotional triggers. Using emotional assessment tools regularly, and being an astute observer of the patient’s preferences can help discern connections between specific behaviors and emotional triggers. Ask the patient and the patient’s family about changes at home and educate family and caregivers about the importance of stress management -- for everyone.N= Neurological disorder and Nutritional Deficiency

The neurological disorder Normal Pressure Hydrocephalus (NPH) occurs when too much cerebrospinal fluid builds up in the ventricles over time and results in symptoms that mimic both Alzheimer’s and Parkinson’s. Fortunately, NPH can be treated successfully once it is correctly diagnosed. But it has to be considered, in order to be diagnosed.

Nutritional deficiencies can also be grouped with the metabolic disorders, but since nutrition starts with an “N,” we will list it here as a way to distinguish intake from deficiency. Deficiencies of specific nutrients, especially of the B vitamins, are worthy of consideration when evaluating a patient for dementia because vitamin B-12 plays a key role in regulating the nervous system. Deficiency of Vitamin B-12 can lead to fatigue, confusion, irritability, and depression that may be mistaken for dementia. Questions about diet and a simple lab test can rule this in or out quickly, but again, it must be considered.T= Tumors and Trauma

Space occupying lesions can grow slowly, and symptoms are likely to be consistent with the part of the brain where the lesion is located. Remember that our elderly patients may not show the same signs of trauma as our younger patients. Because an older person’s brain can atrophy in such a way that there is more space between the cranium and brain tissue, when the older patient suffers a head injury, the signs of a hemorrhage and increased intracranial pressure are unlikely to show up right away. As such, the patient may not associate the injury with the symptoms. This is when it can be helpful to ask the family or caregiver for input.

I= Infection

Infectious processes, including an abscessed tooth or a urinary tract infection, can cause dementia-like symptoms. UTIs frequently occur --and are likely to go undetected in elderly women-- so be sure you make it a part of your practice to rule this out right away when your elderly female patients experience cognitive changes.

A= Alcohol

It is important to be aware that alcohol abuse among older patients is more prevalent than most people may think. Changes in lifestyle, health, family, role, and support system that come with aging may incite a desire to self-medicate. This can be especially dangerous or older adults who tend to have a slower metabolism and a longer list of prescription medications, most of which do not mix well with alcohol. When nurses are aware of the possibilities and take the time to ask the right questions, patients can get the help they need. Beyond abusive self-medication with alcohol, there is alcohol-induced dementia which is also referred to as alcohol-related brain damage. While the symptoms may match other forms of dementia, the onset of symptoms may occur in patients as young as in their 40s or 50s. When properly diagnosed and treated, these patients can recover.

You’ll likely see other versions of the DEMENTIA mnemonic. My first exposure to the DEMENTIA mnemonic was in the Memory Notebook of Nursing (Vol. 2, 3rd ed., Nursing Education Consultants Inc. 2007. p. 78). I’ve seen several different variations from various sources in what the letters stand for—some versions group drugs and alcohol together, others will separate endocrine from metabolic and so on. The version I’ve included in this article is a compilation of different variations that has helped me immensely in my care of elderly patients. I hope it will help you in your practice also.

Questions for Comment:

Have you seen different versions of this mnemonic? Have you ever had a patient who was labeled with dementia who had one of the reversible causes listed above? What tips can you share for working with patients who have dementia?